Somatoform Disorders

Somatoform disorders are a group of psychological conditions where the physical symptoms are present in the patient and it cannot be attributed to any medical condition or substance abuse. The term somatoform disorder has been replaced by a newer term in DSM 5 namely the somatic symptom disorder. The cognitive behavioral therapy constitutes the main mode of treatment of this disorder. The antidepressant has shown beneficial effect in the pain of the somatoform disorder. This disorder would be described in detail in this article.

Definition of Somatoform Disorders

Somatoform disorders are characterized by the presence of one or more somatic symptoms that cause significant distress to the individual and is associated with persistent thoughts about the seriousness of such symptoms. The symptoms are usually mild, but to the patient, they can cause a significant amount of anxiety. The patient might devote excessive time and energy to figure out why they have these somatic symptoms hoping to find a way to treat them.

Epidemiology of Somatoform Disorders

Prevalence

The estimated prevalence of somatoform disorders in the general population is around 0.1%. This is most likely due to under-reporting issues. Epidemiological studies that used inclusion criteria that are more loose compared to those imposed by the DSM-5 found the prevalence of somatoform disorders in the community may be as high as 11%.

Body dysmorphic disorder, which is a specific form of somatoform disorders, was found to be more common in patients visiting plastic and cosmetic surgery offices. Conversion disorder, which is also a specific form of somatoform disorders, had a prevalence of 15% in psychiatric hospitals. Accordingly, specific forms of somatoform disorders might have a higher prevalence in certain groups and populations.

Gender and Race

There is an increase in preponderance of the occurrence of somatoform disorders in females when compared to males. The female to male ratio is 10 to 1. Other risk factors include illiteracy and belongingness to the minority groups in terms of the race and the lower socioeconomic status.

Attention seeking behavior

Many of the people who come with somatoform disorder basically have an attention seeking behavior with that of the healthcare community (though it does not qualify to that of the malingering). This results in the increase in the number of visits by the patient to the hospital.

Impairment of the routine activities

The people with this condition also have the habit of impairment in the activities at their workplace. This results in deterioration in performance in the work related activity which may culminate in the loss of the employment. This creates further stress and would aggravate the symptoms of the somatoform disorder.

Age of Onset

It is important to know that somatoform disorders are expected to start manifesting in late childhood or adolescence. Adults who present with a somatoform disorder for the first time in their life should undergo a full diagnostic workup to exclude occult organic medical conditions.

Etiology of Somatoform Disorders

Link between depression and anxiety

The condition has a link to depression and anxiety. Many studies demonstrated that there is a two-way link between these disorders and the somatoform disorder.

Familial preponderance

There are studies which highlight the increased prevalence of the somatoform disorder among people with a family history of somatoform disorder. This outlines that genetic factor may play a role, although the genes responsible have not been identified.

Stressful events

The other significant etiologies for this disorder include the exposure of the patient to sexual abuse and physical violence at a younger age. The physical symptoms are basically a means of expressing the distress and discomfort which a person experiences.

Escape mechanism by seeking medical attention

As described in the epidemiology the patient with this disorder oftenly take the sick role, which gives them relief from stressful or impossible interpersonal expectations. This is exhibited as an escape mechanism by the patient against any work, which he is bound to do.

Classification of Somatoform Disorders

The classification of somatoform disorder include the following types according to DSM IV

This includes the following:

Somatization disorder

This is characterized by physical symptoms without any physical cause,it has some different symptoms such as;

pain

fatigue

Nausea

Diarrhea

Vomiting

Headache

Constipation

Abdominal pain

Painful intercourse

Painful menstruation

Body dysmorphic disorder

The patient believes that his body parts are defective. There will also be excessive concern over the body image and are obsessed with what are actually minor flaws in their physical appearance, or might perceive flaws where none actually exist. Symptoms associated with this disoder include;

Avoiding mirrors

Depression and anxiety

Avoiding being seen in public

Withdrawal from social situations

Constant checking of appearance in a mirror

Desiring reassurance from others about the person’s appearance

Illness anxiety disorder

This is also known as Hypochondriasis, it is a condition whereby the patient constantly thinks that minor symptoms are a representation of an impending serious medical condition. Symptoms include;

Reslessness

Depression

Constant visits to a doctor until a diagnosis is made

Feeling that a doctor has made a mistake by not diagnosing the cause of the symptom

Conversion disorder

This condition is diagnosed when people have neurological symptoms that can’t be traced back to a medical cause.Symptoms of this disorder may include;

Weakness or paralysis

Abnormal movements (such as tremor or unsteady gait)

Blindness

Hearing loss

Loss of sensation or numbness

Pathophysiology of Somatoform Disorders

The etiology constitutes the main pathological reason behind the occurrence of the disease. The disease is associated with well-known changes in the brain as well as neurotransmitter signaling.

Recent advances in understanding the pathophysiology of somatoform disorders

Patients with a somatoform disorder were found to have a smaller amygdala volume compared to healthy subjects. Moreover, the connectivity patterns between the amygdala and the prefrontal cortex is not normal in patients with somatoform disorders. These brain regions are involved with emotion, thought processing, and perception of somatic symptoms. Therefore, scientists believe that these are the brain regions one would expect to be impaired in a patient with a somatoform disorder and they accepted the brain imaging results of these recent studies.

Symptoms of Somatoform Disorders

The person becomes increasingly recognized of the discomfort which occurs normally to anyone. These discomforts are presented as physical symptoms by the patient. The patient reports of a large collection of the symptoms which could not be clearly attributed to any of the medical disorder. This is the characteristic feature for the diagnosis of this condition.

Variety of symptoms

The symptom might be related to :

Pain (back pain, joint pain)

Cardiovascular related symptoms (pain in the chest, shortness of the breath)

Neurological symptoms (seizures which are known as pseudoseizures , loss of memory , walking difficulty)

Female sexual gland related problems (excessive bleeding during the menstrual cycle., pain during the passage of the urine).

The patient goes from one doctor to another in order to get treated for the symptom. This is known as doctor shopping.

Missing of an organic lesion

The chance of missing an organic condition (due to some lesion or disease) and falsely tagging a particular patient as suffering from the somatoform disorder is rare. Even if this wrong classification occurs, that would only constitute a small proportion of patients.

Progression and Special forms

The occurrence of the conversion disorder, hypochondriasis, development of the anxiety/ depression and factitious disorder, constitute the progression from initial presentation of the somatoform disorder with only a few symptoms. In the case of the conversion disorder the patient experience actual physical symptoms such as blindness, paralysis

Diagnosis of Somatoform Disorders

Differentiation from the comorbid psychiatry condition

There is a significant amount of controversy in the diagnosis of the somatic symptom disorder. These patients generally present with depression and anxiety as comorbid condition. Some also have personality disorder as an additional feature with the somatization disorder.

Presence of history of doctor shopping

The doctor needs to pay attention to the patient’s symptoms in order to gain his confidence. Doctor shopping that the patient may have done also aid the doctor in identification of the patient.

Reason behind the manifestation

The doctor should be trying to identify the reason behind the manifestation of the somatoform disorder, which could be due to some personal or social stress which the patient would have undergone in the past.

The doctor should also address physical abuse and social abuse, which could be the reason for the patient’s current manifestation.

In addition to this, in order to rule out other condition history of substance abuse and alcoholic addiction should also be looked into.

Note:

The older name of the Somatoform disorder (DSM IV and ICD 10) has been replaced by the Somatic Symptom Disorder (DSM -5).

Differential diagnosis of Somatoform Disorders

Anxiety, depression and panic attacks: The key differential diagnosis includes depression and anxiety. The person might be on substance abuse and that may manifest in the symptom. The person might have had some panic attack.

Malingering: It is very important in distinguishing this condition from that of malingering which is intentionally faking a condition for the gains in personal or achieving a criminal motive.

Organic disorder: There is also a possibility that an organic disorder might be actually present in the patient and thus leading to the manifestation of the symptom. Generally,there are many symptoms that are unrelated, hence the diagnosis of the somatoform disorder is made.

Unknown disease condition: There is also another possibility that the symptoms may be real and the symptoms are due to a disease whose etiology is not fully explored and diagnosed.

Therapy of Somatoform Disorders

The two main modalities of the treatment which are recognized for the somatoform disorder are behavioral psychotherapy and pharmacotherapy. Both have its own role and the physician need to strike a balance in the employment of both the strategies for the benefit of the patient. The behavioral psychotherapy is widely employed.

General treatment attributes

The patient should be assured that his clinical scenarios is overlooked and the physician should gain confidence of the patient. This will essentially treat the attention seeking behavior part of the somatoform disorder. The clinician should also spend time in listening to the grievances of the patient and address them with concern.

Attention by the clinician:

The attention needs to be given to the symptoms of the patient by the clinician and this will instill a positive feeling in the patient. The patient should be then gradually advised to avoid presenting to the clinic with symptoms.

Insignificance of numerous laboratory investigations

The unnecessary laboratory investigation which are done with the intent of pleasing the patient have not resulted in the improvement of the symptoms. Hence the laboratory investigation should be restricted to the minimum (just to aid the diagnosis).

Cognitive behavioral therapy

The cognitive behavioral therapy is superior over the pharmacological therapy in the treatment of somatoform disorder. The patient should not be directly questioned about his symptom since this will affect his perception about sharing the information to the clinician. In addition to this, other psychological therapies which has shown beneficial effect include relaxation therapy, family therapy, the education of the patient himself.

Pharmacotherapy

Antidepressants and other agents

Antidepressants has shown beneficial effects in the treatment of pain in somatoform disorder. There is no difference in terms of the efficacy of the various antidepressant, although some results have shown that the tricyclic antidepressant are more likely to respond when compared to that of the SSRI. There is also a role in the addition of typical antidepressant such as SSRI in the therapy for the treatment. The other therapy includes SNRI(Serotonin and Noradrenaline Reuptake Inhibitor), atypical antipsychotics and medication of herbal origin.

Treatment of special form

In special form such as hypochondriasis, body dysmorphic syndrome, SSRI has shown beneficial effect. SNRI has shown to be more effective in conditions in which the pain is the predominant symptom. It is recommended to avoid opioid drugs in the treatment of pain in these patients.

Emergency treatment

Patients with somatoform disorders might present to the emergency department with excessive anxiety. Benzodiazepines might be indicated to lower the anxiety level of the patient. Opiates were found to be associated with a high risk of drug dependence in patients with somatoform disorders and should be avoided.

Complications

The complication includes :

Deterioration in the health of the person

The development of the disability in the patient

Development of anxiety and depression in the later stage

The risk of suicide

Problem in the family and at work

Financial distress

Prevention of Somatoform Disorders

Though the exact method of prevention of somatoform disorder is not well established, one of the important factors is to avoid the vulnerability of the person to be sexually or physically abused. A person who has experienced abuse in a physical or mental form should be given proper counselling and support. The prevention of substance abuse in the early stage along with proper realization of the patient in the initial stage itself that he needs psychiatric counselling for the control of his symptom will avoid the progression of the symptom in the future.